Emergency department bounceback characteristics for patients diagnosed with COVID-19.

BACKGROUND: The global healthcare burden of COVID-19 continues to rise. There is currently limited information regarding the disease progression and the need for hospitalizations in patients who present to the Emergency Department (ED) with minimal or no symptoms. OBJECTIVES: This study identifies bounceback rates and timeframes for patients who return to the ED due to COVID-19 after initial discharge on the date of testing. METHODS: Using the NorthShore University Health System's (NSUHS) Enterprise Data Warehouse (EDW), we conducted a retrospective cohort analysis of patients who were tested positive for COVID-19 and were discharged home on the date of testing. A one-month follow-up period was included to ensure the capture of disease progression. RESULTS: Of 1883 positive cases with initially mild symptoms, 14.6% returned to the ED for complaints related to COVID-19. 56.9% of the mildly symptomatic bounceback patients were discharged on the return visit while 39.5% were admitted to the floor and 3.6% to the ICU. Of the 1120 positive cases with no initial symptoms, only four returned to the ED (0.26%) and only one patient was admitted. Median initial testing occurred on day 3 (2-5.6) of illness, and median ED bounceback occurred on day 9 (6.3-12.7). Our statistical model was unable to identify risk factors for ED bouncebacks. CONCLUSION: COVID-19 patients diagnosed with mild symptoms on initial presentation have a 14.6% rate of bounceback due to progression of illness.

Results from the First Year of Implementation of CONSULT: Consultation with Novel Methods and Simulation for UME Longitudinal Training.

INTRODUCTION: An important area of communication in healthcare is the consultation. Existing literature suggests that formal training in consultation communication is lacking. We aimed to conduct a targeted needs assessment of third-year students on their experience calling consultations, and based on these results, develop, pilot, and evaluate the effectiveness of a consultation curriculum for different learner levels that can be implemented as a longitudinal curriculum. METHODS: Baseline needs assessment data were gathered using a survey completed by third-year students at the conclusion of the clinical clerkships. The survey assessed students' knowledge of the standardized consultation, experience and comfort calling consultations, and previous instruction received on consultation communication. Implementation of the consultation curriculum began the following academic year. Second-year students were introduced to Kessler's 5 Cs consultation model through a didactic session consisting of a lecture, viewing of "trigger" videos illustrating standardized and informal consults, followed by reflection and discussion. Curriculum effectiveness was assessed through pre- and post- curriculum surveys that assessed knowledge of and comfort with the consultation process. Fourth-year students participated in a consultation curriculum that provided instruction on the 5 Cs model and allowed for continued practice of consultation skills through simulation during the Emergency Medicine clerkship. Proficiency in consult communication in this cohort was assessed using two assessment tools, the Global Rating Scale and the 5 Cs Checklist. RESULTS: The targeted needs assessment of third-year students indicated that 93% of students have called a consultation during their clerkships, but only 24% received feedback. Post-curriculum, second-year students identified more components of the 5 Cs model (4.04 vs. 4.81, p<0.001) and reported greater comfort with the consultation process (0% vs. 69%, p<0.001). Post- curriculum, fourth-year students scored higher in all criteria measuring consultation effectiveness (p<0.001 for all) and included more necessary items in simulated consultations (62% vs. 77%, p<0.001). CONCLUSION: While third-year medical students reported calling consultations, few felt comfortable and formal training was lacking. A curriculum in consult communication for different levels of learners can improve knowledge and comfort prior to clinical clerkships and improve consultation skills prior to residency training.

Examining emergency department communication through a staff-based participatory research method: identifying barriers and solutions to meaningful change.

STUDY OBJECTIVE: We test an initiative with the staff-based participatory research (SBPR) method to elicit communication barriers and engage staff in identifying strategies to improve communication within our emergency department (ED). METHODS: ED staff at an urban hospital with 85,000 ED visits per year participated in a 3.5-hour multidisciplinary workshop. The workshop was offered 6 times and involved: (1) large group discussion to review the importance of communication within the ED and discuss findings from a recent survey of patient perceptions of ED-team communication; (2) small group discussions eliciting staff perceptions of communication barriers and best practices/strategies to address these challenges; and (3) large group discussions sharing and refining emergent themes and suggested strategies. Three coders analyzed summaries from group discussions by using latent content and constant comparative analysis to identify focal themes. RESULTS: A total of 127 staff members, including attending physicians, residents, nurses, ED assistants, and secretaries, participated in the workshop (overall participation rate 59.6%; range 46.7% to 73.3% by staff type). Coders identified a framework of 4 themes describing barriers and proposed interventions: (1) greeting and initial interaction, (2) setting realistic expectations, (3) team communication and respect, and (4) information provision and delivery. The majority of participants (81.4%) reported that their participation would cause them to make changes in their clinical practice. CONCLUSION: Involving staff in discussing barriers and facilitators to communication within the ED can result in a meaningful process of empowerment, as well as the identification of feasible strategies and solutions at both the individual and system levels.

Is female sex associated with ED delays to diagnosis of appendicitis in the computed tomography era?

BACKGROUND: Historically, females had delays to definitive diagnosis of appendicitis when compared to males. In this current millennium, appendicitis is now most commonly diagnosed by computed tomography (CT) in the emergency department (ED) rather than at surgery. OBJECTIVE: The aim of the study was to assess if female gender is still associated with delays to diagnosis of appendicitis in the CT era. METHODS: A retrospective cohort analysis of adult patients with appendicitis at a university teaching hospital ED was conducted. Inclusion criteria was age of more than 18 years and an International Classification of Diseases, Ninth Revision (ICD-9), diagnosis of appendicitis. Patients were excluded from analysis if they were pregnant, no CT scan was obtained in the ED, or had incomplete outcome data. RESULTS: One hundred thirty-seven patients met inclusion criteria; 65 female, 72 males. Time from triage to CT order was 138 minutes in females and 95 minutes in males (P = .0012). Time from initial physician evaluation to CT order was 45 minutes in females and 28 minutes in males (P = .0012). Nonclassic symptoms were more common in females and pelvic evaluation did not delay the CT order. CONCLUSION: Female gender is still associated with delays to CT acquisition and diagnosis of appendicitis.

Therapy for acute heart failure syndromes.

The pharmacologic management of acute heart failure syndromes (AHFS) has changed little over the past 15 years. Traditional therapies, such as nitrates and loop diuretics, remain the mainstay of therapy, with inotropes reserved for patients who present in shock or an advanced low-output state. We review the use of these therapies in AHFS with added insights from recent clinical trials and registry data.

Patient perspectives on communication with the medical team: pilot study using the Communication Assessment Tool-Team (CAT-T).

OBJECTIVE: Effective communication is an essential aspect of high-quality patient care and a core competency for physicians. To date, assessment of communication skills in team-based settings has not been well established. We sought to tailor a psychometrically validated instrument, the Communication Assessment Tool, for use in Team settings (CAT-T), and test the feasibility of collecting patient perspectives of communication with medical teams in the emergency department (ED). METHODS: A prospective, cross-sectional study in an academic, tertiary, urban, Level 1 trauma center using the CAT-T, a 15-item instrument. Items were answered via a 5-point scale, with 5 = excellent. All adult ED patients (> or = 18 y/o) were eligible if the following exclusion criteria did not apply: primary psychiatric issues, critically ill, physiologically unstable, non-English speaking, or under arrest. RESULTS: 81 patients were enrolled (mean age: 44, S.D. = 17; 44% male). Highest ratings were for treating the patient with respect (69% excellent), paying attention to the patient (69% excellent), and showing care and concern (69% excellent). Lowest ratings were for greeting the patient appropriately (54%), encouraging the patient to ask questions (54%), showing interest in the patient's ideas about his or her health (53% excellent), and involving the patient in decisions as much as he or she wanted (53% excellent). CONCLUSION: Although this pilot study has several methodological limitations, it demonstrates a signal that patient assessment of communication with the medical team is feasible and offers important feedback. Results indicate the need to improve communication in the ED. PRACTICE IMPLICATIONS: In the ED, focusing on the medical team rather then individual caregivers may more accurately reflect patients' experience.